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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
Kavita K. Patel, MD, MS
Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population
Maureen J. Lage, PhD
Authors’ Reply to “Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population”
Eric T. Wittbrodt, PharmD, MPH; James M. Eudicone, MS, MBA; Kelly F. Bell, PharmD, MSPhr; Devin M. Enhoffer, PharmD; Keith Latham, PharmD; and Jennifer B. Green, MD
Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms
Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Deaths Among Opioid Users: Impact of Potential Inappropriate Prescribing Practices
Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
Do Health Systems Respond to the Quality of Their Competitors?
Daniel J. Crespin, PhD; Jon B. Christianson, PhD; Jeffrey S. McCullough, PhD; and Michael D. Finch, PhD
Impact of Clinical Training on Recruiting Graduating Health Professionals
Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
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Does Care Consultation Affect Use of VHA Versus Non-VHA Care?
Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH

Does Care Consultation Affect Use of VHA Versus Non-VHA Care?

Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH
Uncoordinated multisystem use is problematic for Veterans Health Administration (VHA) patients with dementia. The Partners in Dementia Care intervention is successful in changing the pattern of VHA versus non-VHA use.
ABSTRACT

Objectives: The Partners in Dementia Care (PDC) intervention has shown improved psychosocial outcomes while reducing overall inpatient and emergency department (ED) utilization among veterans with cognitive impairment and behavioral symptoms. However, veterans who use the Veterans Health Administration (VHA) also seek care from non-VHA sources, potentially reducing the effectiveness of care coordination. We evaluated whether PDC affected VHA and non-VHA inpatient and ED use by veterans with dementia.

Study Design: PDC is a telephone-based care coordination and support service program implemented in 2 VHA intervention sites that were compared with 3 VHA control sites. Veterans with a dementia diagnosis and their caregivers participated.

Methods: Data came from administrative records and structured interviews with caregivers. We modeled the likelihood of site of care across 3 periods: preintervention (baseline), baseline to 6 months, and 6 months to 12 months.

Results: Compared with veterans at control sites, veterans at intervention sites who lived closer to VHA medical centers showed an increase over time (P ≤.01) in the likelihood of seeking VHA inpatient care as opposed to non-VHA care, whereas the likelihood of seeking non-VHA relative to VHA inpatient care increased for veterans living further away. ED visits did not show a comparable intervention effect.

Conclusions: PDC intervention affected the choice of VHA versus non-VHA inpatient care, with its impact differing by distance from VHA medical centers. Site of ED care was not affected. Accountable care organizations share some of the VHA’s vulnerabilities to out-of-system use; thus, the implications of our findings extend beyond the VHA system.

Am J Manag Care. 2019;25(4):e119-e125
Takeaway Points

Non–Veterans Health Administration (VHA) care can be poorly coordinated with VHA care, which can be problematic for high-need patients with dementia. Partners in Dementia Care (PDC) is a care coordination intervention shown to lessen dementia-related needs and improve outcomes. However, the impact of care coordination on use of VHA versus non-VHA care has not been examined.
  • The PDC intervention is successful in changing the pattern of VHA versus non-VHA use. 
  • Its impact differs for inpatient versus emergency/urgent care and by distance from VHA medical centers.
  • Accountable care organizations share some of the VHA’s vulnerabilities to out-of-system use, extending the implications of our findings.
Individuals with dementia, their families, and their friends are affected by the disease on personal, emotional, and financial levels. In 2017, 47 million individuals had dementia worldwide; that number is projected to increase to 75 million by 2030.1 The Veterans Health Administration (VHA), the largest healthcare system in the United States, provides care to more than 270,000 veterans with dementia.2

Partners in Dementia Care (PDC) is a telephone-based care coordination and support service intervention for veterans with dementia and their family caregivers, delivered through partnerships between VHA medical centers and local Alzheimer’s Association (AA) chapters. It was designed to integrate health, community, and support services to address the unmet care needs of patients and caregivers across all dementia stages.3-5 PDC has been shown to lessen dementia-related needs and improve psychosocial outcomes for patients and caregivers.3-8 Our prior work has shown that PDC can reduce inpatient admissions and emergency department (ED) visits among veterans with cognitive impairment and behavioral symptoms9 without significantly increasing VHA healthcare costs.10

The positive outcomes from PDC and other care coordination interventions are encouraging.11-14 However, veterans who use VHA care also frequently use non-VHA care.15-18 Among veterans with dementia, veteran status (priority level) influences where veterans seek care, as do need (eg, comorbidities, functional limitations) and the presence of enabling or disenabling factors (eg, possession of other insurance, income level, distance from VHA facilities, education).19,20 Out-of-system use places veterans at risk for poor coordination of care and possible over- or underuse of services.20 Prior studies have examined factors that appear to be associated with choice of care site (VHA vs non-VHA), but these studies are descriptive. We have not found any work examining whether a care coordination intervention, such as PDC, can change patients’ choices of site of care.

The PDC project (2006-2011) was intended to enhance access to VHA and non-VHA services and improve integration of medical care and the network of community service organizations. If PDC was successful in improving VHA access, we anticipated that care-seeking patterns across VHA and non-VHA facilties would shift toward the VHA among intervention participants but not among participants in the control (usual care [UC]) group.

METHODS

Sample Design

Participants were recruited over 2.5 years from 5 communities.21 All sites were located in 1 of 2 selected Veterans Integrated Service Networks (VISNs), which provide a unifying administrative structure for VHA services within a geographic region. Study sites were matched within VISNs to assure uniformity in this administrative structure. Matched VHA medical centers were similar in size, inpatient and outpatient services, academic affiliations, research missions, and medical residency programs. Matched AA chapters were similar in size and programs. VISN 16, which includes Houston, Texas; Beaumont, Texas; and Oklahoma City, Oklahoma, was chosen because it was the location of the study’s VHA principal investigator (M.E.K.). The other selected VISN (VISN 1), which includes Boston, Massachusetts, and Providence, Rhode Island, had an array of VHA and AA services similar to that of VISN 16. The intervention site was chosen randomly within each set of matched sites. Site randomization was used to allow PDC implementation throughout partnering organizations, minimizing diffusion to UC veterans. Boston and Houston served as PDC sites, and Providence, Oklahoma City, and Beaumont served as control (UC) sites.

PDC recruited veterans (Table 1) and their caregivers. Veterans’ eligibility criteria included receiving primary care from the VHA, living outside an institutional setting, being 50 years or older, and having at least 1 International Classification of Diseases, Ninth Revision, Clinical Modification dementia diagnostic code (290.41-290.43, 291.2, 292.82, 294.1, 294.8, and 331.0) in the medical record. VHA primary care physicians confirmed eligibility prior to sampling. Eligibility was not restricted by dementia severity or symptoms. Caregivers’ eligibility criteria included being an unpaid family member or friend and being the individual who provided the most assistance with a veteran’s personal care, daily living tasks, and/or health-related decisions. Although infrequent, veterans with dementia could enroll without a caregiver if they were determined to have the capacity to consent using the Blessed Orientation–Memory–Concentration Test administered over the phone.22

Intervention

PDC addressed prominent problems reported by study participants, including fragmentation and lack of coordination between medical care and community services.23,24 The intervention was implemented by a half-time VHA dementia care coordinator (DCC) and a half-time AA care consultant (CC). Each DCC/CC pair worked together. VHA DCCs primarily focused on veterans’ medical and nonmedical needs and assisted families with effectively using VHA resources; AA CCs primarily focused on the needs of informal caregivers, such as care-related strain and accessing non-VHA resources.

The intervention consisted of (1) assessment of care needs across medical and nonmedical care issues, (2) development of care goals matching the priorities of veterans and caregivers, (3) development of action steps to move participants toward goal achievement, and (4) ongoing monitoring of action steps. Patients and caregivers in both the PDC and UC arms received printed materials about dementia.25 Study data came from veterans’ VHA medical records and 3 structured telephone interviews conducted with caregivers at baseline, 6 months, and 12 months. The baseline interview occurred prior to distributing dementia educational materials and implementing PDC at intervention sites.22


 
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